Hospitalized patients with
hepatic insufficiency often suffer from severe catabolic states and are in urgent need of
nutritional support during their acute illness.
Protein intolerence, however, remains a significant problem with respect to the provision of adequate nutrition, either enterally or parenterally. The following report is an anecdotal series of 63 consecutive patients in a large urban hospital treated prospectively with
nutritional support using a prototype high
branched-chain amino acid solution (FO80) given by technique of
total parenteral nutrition by the subclavian or internal jugular route with hypertonic
dextrose. Sixty-three patients, of which 42 had chronic
liver disease (
cirrhosis) with acute decompensation and 17 with acute hepatic injury as well as four with
hepatorenal syndrome, are the subject of this report. All required intravenous
nutritional support and were either intolerant to commercially available
parenteral nutrition solutions or were in
hepatic encephalopathy at the time they were initially seen. The cirrhotic patients had been hospitalized for a mean of 14.5 +/- 1.9 days before
therapy, had a mean
bilirubin of 13 mg/100 ml, and had been in
coma for 4.8 +/- 0.7 days despite standard
therapy. Patients with acute
hepatitis had been in the hospital for 16.2 +/- 4.1 days before
therapy, had a mean
bilirubin of 25 mg/100 ml, and had been in
coma 5.2 +/- 1.6 days before
therapy. Routine tests of liver function, blood chemistries,
amino acids, EEGs, and complex neurological testing including Reitan trailmaking tests were used in the evaluation of these patients. Up to 120 grams of synthetic
amino acid solution with hypertonic
dextrose was tolerated in these patients with improvement noted in
encephalopathy of at least one grade in 87% of the patients with
cirrhosis and 75% of the patients with
hepatitis.
Nitrogen balance was achieved when 75 to 80 grams of synthetic
amino acids were administered. Survival was 45% in the cirrhotic group and 47% in the acute
hepatitis group.
Encephalopathy appeared to correlate with individual
amino acids differentially in the various groups and with the ratio between the aromatic and the
branched-chain amino acids.
Ammonia did not correlate with either the degree of
encephalopathy or improvement therefrom. In 24 Patients
therapy for
hepatic encephalopathy was limited to infusion of the branched-chain enriched
amino acid solution only, with wake-up in 66% of this group. The results strongly suggest that in
protein intolerant patients requiring
nutritional support, infusion with branchedchain enriched
amino acid solutions is well tolerated with either no worsening of or improvement in
hepatic encephalopathy coincident with the achievement of
nitrogen equilibrium and adequate
nutritional support.